General Medical Consent

I authorize Medical Weight Loss Centers of America, LLC and whomever this entity designates as its medical providers to assist me in my weight reduction efforts.

I understand my treatment may involve, but is not to be limited to, the use of: appetite suppressants for more than 12 week when indicated, balanced diet, regular exercise, and instructions on behavior modification techniques.

I have read and understand my doctor’s statement that is listed below. “Medications, including the appetite suppressants, have labeling worked out between the makers of the medication and the Food and Drug Administration. This labeling contains among other things, suggestions for using this medication. The appetite suppressant labeling suggestions are generally based on shorter term studies (up to 12 weeks) using the dosages indicated in the labeling.”

I understand it is my responsibility to follow the instructions carefully and to report to the health care provider (Physician/NP/PA) treating me for my weight, any significant medical problems and medical history, and change in medications, as soon as reasonably possible. I understand my continuing to receive the appetite suppressant will be dependent on my progress in weight reduction and weight maintenance.

I understand this authorization is given with the knowledge that the use of appetite suppressants for more than 12 weeks and in higher doses than the doses indicated in the labeling involves some risks and hazards. The more common include: nervousness, sleeplessness, headaches, dry mouth, weakness, tiredness, psychological problems, medication allergies, high blood pressure, rapid heart beat, and heart irregularities. Less common, but more serious risks are primary pulmonary hypertension and heart disease. These and other possible risks could, on occasion, be serious or fatal.

I understand I need to stop taking the appetite suppressant if swelling, shortness of breath, heart arrhythmia, increasing blood pressure or heart fluttering develops and notify the health care provider.

I understand that much of the success of the program will depend on my efforts and that there are no guarantees or assurances that the program will be successful.

I understand I cannot obtain appetite suppressants elsewhere while taking the medication from this clinic.

I understand this is a prescription medication and it is illegal to share with anyone else. I cannot receive medication early for any reason including lost or stolen pills.

I understand I cannot get refills on medication without meeting with the health care provider unless the following criteria are met; It has been over 21 days since the last refill, bloodwork is less than 90 days old, there are no new medications or side effects, there has been weight loss.

I am asking for medical care and treatment at this practice and agree to accept services which may diagnose a medical condition, procedures to treat my condition and routine medical care. I understand that these services will be provided to me by physicians, nurse practitioners, physician assistants and other health care providers, some of whom may be in training. I have not been given any guarantees as to the results of the services I will receive.

I understand that my agreement to accept these services will remain in effect unless I say that I no longer want these services or until my treatment is completed.

I understand that my agreement to accept these services is called a General Consent and that it includes any routine procedure(s) or treatment(s) such as blood drawing, physical examination, administration of medication(s), and other non-invasive procedures.

I understand there are no refunds or returns.